306 volume 40 | number 5 September/October 2015

Margaret Manfre, BSN, RN, IBCLC Donita Adams, BS, RNC

Gloria Callahan, RN Patricia Gould, BSN, RNC

Susan Lang, RN, IBCLC Holly McCubbins, BSN, RN

Amy Mintz, BSN, RN Sommer Williams, RNC Mark Bishard, Pharm-D

Amy Dempsey, MSN, RNC and Marianne Chulay, PhD, RN, FAAN

Hydrocortisone Cream TO REDUCE

Perineal Pain After Vaginal Birth:

Abstract Purpose: To determine if the use of hydrocortisone cream decreases perineal pain in the immediate postpartum period. Study Design and Methods: This was a randomized controlled trial (RCT), crossover study design, with each participant serving as their own control. Participants received three different methods for perineal pain management at three sequential perineal pain treatments after birth: two topical creams (corticosteroid; placebo) and a control treatment (no cream application). Treatment order was randomly assigned, with participants and investigators blinded to cream type. The primary dependent variable was the change in perineal pain levels (posttest minus pretest pain levels) immediately before and 30 to 60 minutes after perineal pain treatments. Data were analyzed with analysis of variance, with p < 0.05 considered signifi cant. Results: A total of 27 participants completed all three perineal pain treatments over a 12-hour period. A reduction in pain was found after application of both the topical creams, with average perineal pain change scores of −4.8 ± 8.4 mm after treatment with hydrocortisone cream (N = 27) and −6.7 ± 13.0 mm after treatment with the placebo cream (N = 27). Changes in pain scores with no cream application were 1.2 ± 10.5 mm (N = 27). Analysis of variance found a signifi cant difference between treatment groups (F

2,89 = 3.6, p = 0.03), with both cream treatments having

signifi cantly better pain reduction than the control, no cream treatment (hydrocortisone vs. no cream, p = 0.04; placebo cream vs. no cream, p = 0.01). There were no differences in perineal pain reduction between the two cream treatments (p = .54). Clinical Implications: This RCT found that the application of either hydrocortisone cream or placebo cream provided signifi cantly better pain relief than no cream application. Key words: Hydrocortisone cream; Perineal pain postpartum; Randomized controlled trial; Visual analog scale.

P erineal pain after vaginal birth, either from tissue damage during birth, infl ammation during second-stage pushing, or from an episiotomy, is a common source of postbirth discomfort, being most severe on the fi rst day after birth (Hedayati, Parsons, & Crowther, 2005). Steen (2008) found that women on the fi rst day after giving birth de-

scribed their perineal pain using words such as sore, aching, throbbing, tender, stinging, and uncomfortable. Many postpartum women require analgesic medications to control the perineal discomfort (Petersen, 2011). At our institution, acetaminophen and ibuprofen are routinely available as needed, and additionally, hydrocodone or oxycodone can be ordered if requested. Other interventions commonly used to de- crease perineal discomfort include application of topical medications to provide a local anesthetic and/or anti-infl ammatory effect directly to the injured perineal tissue. Standard interventions available at our hospital are similar to other hospitals in our region and include cold therapy (ice packs), heat therapy (warm tub bath), benzocaine 20% (Americaine) spray, phenylephrine-mineral oil-petrolatum (Prepara- tion H) ointment, hydrocortisone 1% ointment, and Tucks pads.

A RANDOMIZED CONTROLLED TRIAL

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action for hydrocortisone cream is to reduce infl amma- tion, the primary intent of use in this setting is to reduce the patient’s perception of pain (which may be caused by perineal edema and infl ammation); therefore, we chose not to measure infl ammation but rather focus on pain as the primary outcome.

Reviews of the literature have all emphasized that evi- dence of topical medication effi cacy for managing peri- neal pain is very limited and additional RCTs are needed to properly evaluate the effi cacy of topical medications for perineal pain (East et al., 2012; Heydati et al., 2009; Petersen, 2011). A major concern with prior studies cited in the reviews was the lack of a control group (no peri- neal medication) in the study design. In addition, many of the studies evaluated the product epifoam, which has multiple active ingredients (local anesthetic and hydrocor- tisone). Because hydrocortisone cream without anesthetic agents is a commonly used perineal medication in clinical practice and to date no RCTs have been done to evaluate this method for managing perineal pain, the purpose of this RCT was to determine if hydrocortisone cream de- creases perineal pain in the immediate postpartum period.

Study Design and Methods This study was conducted from June 2013 to May 2014 at Lutheran Medical Center in Wheat Ridge,

CO, a 409-bed not-for-profi t hospital in the Rocky Mountain Region serv- ing a predominantly Caucasian, mid- dle class community. The study site was their 40-bed mother baby unit. The institutional review board of the health system reviewed and approved the study.

Study Design

This was an RCT using a crossover design, with each participant serving as their own control. Participants re- ceived each of three different methods for management of perineal pain after birth: two topical medications (corti- costeroid cream; placebo cream) and a control treatment (no cream applica- tion). Each participant received a treat- ment of topical corticosteroid cream, topical placebo cream, or no treatment at one of three sequential times in the fi rst 12.5 hours after birth. Order of treatments (corticosteroid cream; pla- cebo cream; control) was randomly assigned by a computer-generated number sequencer, with participants and investigators blinded to cream type. The primary dependent variable was the change in perineal pain levels (posttest minus pretest pain levels) im- mediately before and 30 to 60 minutes after application of a topical cream or no cream application.

Despite widespread clinical use, evidence of topical medication effi cacy for managing perineal pain is limited.

The most frequently studied topical method for control- ling perineal pain is cryotherapy, usually in the form of a bag of ice chips or a cooled gel pack applied directly to the injured perineal tissue (Petersen, 2011). A systematic review of 10 randomized controlled trials (RCTs) of cryo- therapy found no evidence to support the effectiveness of local cooling treatments applied to the perineum to relieve pain (East, Begg, Henshall, Marchant, & Wallace, 2012). In a systematic review of RCTs evaluating topical anesthet- ics (lidocaine, cinchocaine, and epifoam in either gel, foam, or spray), Hedayati et al. (2005) found no convincing evi- dence that these agents were more effective in treating post- partum perineal pain than a placebo. Several of the RCTs in the systematic review evaluated epifoam, a topical foam preparation for perineal pain management that included hydrocortisone, along with a topical anesthetic (pramox- ine hydrochloride) (Greer & Cameron, 1984; Hanretty, Davidson, & Cordiner, 1984; Hutchins, Ferreira, & Nor- man-Taylor, 1985). Two of the three studies did not show a signifi cant improvement in perceived pain using epifoam versus a placebo. Given the lack of evidence, as well as the product’s cost ($60.49/10 g canister), epifoam is no longer available on our hospital’s formulary. Hydrocortisone 1% (without the topical anesthetic) is available at our hospi- tal and is routinely ordered by our obstetric providers for treatment of “perineal pain.” Although the mechanism of

September/October 2015 MCN 307

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308 volume 40 | number 5 September/October 2015

Instruments

Perineal pain was measured with a visual analog scale (VAS). Use of the VAS for symptom measurement has been extensively studied for pain measurement in a variety of patient populations and situations, and found to be a valid and reliable measure of pain perception (Gelinas et al., 2008; Hjermstad et al., 2011; Williamson & Hoggart, 2005). One end of the 100 mm VAS vertical line was an- chored by the words, “No Pain at All” and the other end anchored by the words, “Worst Pain Imaginable.” Partici- pants were instructed by a study investigator, and practiced the proper use of the VAS at the time of study consent, prior to beginning study data collection. Scoring of the VAS was done by measuring in mm the distance on the vertical line from the anchor of “No Pain at All” to the intersection with the participant’s horizontal mark of the level of their pain. Pain scores can range from 0 to 100 mm.

Sample Selection

Participants for this study were a convenience sample of postpartum women who had a vaginal birth. Inclusion criteria included presence of a perineal laceration and/or episiotomy, medically stable, and no known sensitivity to hydrocortisone or Witch Hazel.

A minimum sample size of 26 participants (total of 78 treatments) was determined a priori using power analysis for F tests. The primary dependent variable (change in pain scores before and after treatment) was used for sample size calculation. Effect size (ES) was calculated using a standard formula [ES = (mean

groupA – mean

groupB )/SD] (Cohen, 1988;

Faul, Erdfelder, Lang, & Buchner, 2007) and was based on a clinical desire to detect at least a 20% difference in pain scores between the treatments (corticosteroid cream; placebo cream; no cream control). The rationale for setting the pain difference between treatments at 20% was that it would be diffi cult clinically to justify the time, expense, and inconvenience associated with topical medication adminis- tration if pain relief was not of a clinically meaningful level. Estimates of mean ± SD values for the effect size calculation were based on a prior study using the placebo group’s VAS rating of pain at 24 hours postpartum (mean 39 ± 22 mm) (Corkill, Lavender, Walkinshaw, & Alfi revic, 2001). Using these values, the calculated effect size was .36, which is a large effect size for an F test power analysis (Cohen; Faul et al., 2007). Power and alpha levels were set at 0.8 and 0.05, respectively, common parameters for power analysis in health sciences research.

Study Procedure

Investigators were trained in all study procedures prior to data collection. At no time during the study were investi- gators assigned as the participant’s primary nurse. Investi- gators and participants were blinded to treatment group assignment.

A pharmacist prepared the study treatments, includ- ing blinding of the type of cream, and labeling of each perineal treatment with directions for application. A 2-in. long ribbon of hydrocortisone 1% (NDC # 0603- 0535-50 Qualtest Pharmaceuticals, Huntsville, AL) and placebo (similar cetyl alcohol based cream NDC

# 62991-2530-04, Letco Medical, Decatur, AL) creams were extracted from the original tube and repackaged by the pharmacist in individual sterile tubes. Labels for each treatment were clearly marked with the order of administration (1st treatment, 2nd treatment, 3rd treatment), and study ID number. The “no treatment” tube was empty of cream.

On admission to the mother baby unit, women who gave birth vaginally were invited by a study investiga- tor to participate in the study. Within 2 hours of admis- sion to the postpartum unit, a study investigator asked the participant to rate their perineal pain on a VAS (pretest). After rating, the study investigator applied the fi rst randomly assigned perineal treatment (hydro- cortisone cream; placebo cream; no cream) to a Witch Hazel pad (A·E·R, Birchwood Laboratories, Inc., Eden Prairie, MN) and placed the pad directly in contact with the perineum. Thirty to sixty minutes after ap- plication, a study investigator had the participant rate their perineal pain on a VAS (posttest). According to manufacturer recommendations, hydrocortisone cream can be applied four times per day. Therefore, following initial application, this process was repeated every 6 hours for the 2nd and 3rd randomly assigned perineal treatments (hydrocortisone cream; placebo cream; no cream). At no time was the study investigator or par- ticipant aware that treatment cream had been applied by the study investigator.

Throughout the study, participants were allowed pain adjuncts normally available to them for management of perineal pain (topical ice pack; oral ibuprofen; and/ or oral narcotics). No other topical medications or treat- ments were allowed during the 12-hour study period.

Data Analysis

Intent to treat analysis was used in this study. Data were summarized using descriptive statistics. Changes in pain scores were calculated by subtracting pretest val- ues from posttest values for each treatment. Negative change scores indicated decreases in pain, whereas posi- tive change scores denoted increases in pain. Analysis of variance was used to determine if changes in pain scores for the three treatment groups (corticosteroid cream; placebo cream; no cream control) differed from each other and whether treatment order, severity of perineal injury, and/or use of pain adjuncts were signifi cant fac- tors in pain response. Scheffe’s multiple comparison test was used to identify differences between groups. The level of signifi cance for all tests was p < 0.05.

Results A total of 29 participants were enrolled in the study, with 27 participants completing all three study treat- ments. Two study participants never received any study treatments after randomization due to clinical logistical problems resulting in a delay of starting treatment ap- plication in one participant and development of a post- partum hemorrhage requiring study stoppage in another participant. Patient demographics and characteristics for the study participants are summarized in Table 1. Only

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September/October 2015 MCN 309

Table 1. Patient Demographic and Characteristic Data for Postpartum Mothers (N = 29)

Maternal age (years)* 27.7 ± 6.2

(range: 17–39)

Gestational age of baby (weeks/days)* 39.6 ± 1.1 weeks

(range: 37–41 weeks)

Gravidity 1 N = 8 (28%)

2 N = 11 (37%)

3 N = 6 (21%)

≥4 N = 4 (14%)

Parity 1 N = 16 (55%)

2 N = 9 (31%)

3 N = 3 (10%)

≥4 N = 1 (3%)

Episiotomy Yes N = 1 (3%)

No N = 28 (96%)

Perineal injury 1 N = 10 (35%)

2 N = 15 (52%)

3 N = 1 (3%)

4 N = 0

Other (bilateral urethral) N = 3 (10%)

Perineal pain VAS before each

treatment (mm) (N = 27)*

Treatment #1 22.2 ± 21.0 (range: 0–42)

Treatment #2 24.8 ± 22.1 (range: 0–75)

Treatment #3 21.5 ± 23.2 (range: 0–82)

Most common perineal pain adjunct

used at time of treatment (N = 27)

Treatment #1 Ice Pack N = 6 (22%)

Ibuprofen N = 7 (26%)

Ice + Ibuprofen N = 7 (26%)

Ibuprofen + Narcotic N = 1 (4%)

Treatment #2 Ice Pack N = 2 (8%)

Ibuprofen N = 16 (59%)

Ice + Ibuprofen N = 0 (0%)

Ibuprofen + Narcotic N = 2 (8%)

Treatment #3 Ice Pack N = 1 (4%)

Ibuprofen N = 18 (67%)

Ice + Ibuprofen N = 3 (12%)

Ibuprofen + Narcotic N = 1(4%)

* Mean ± SD

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310 volume 40 | number 5 September/October 2015

The use of perineal cream signifi cantly

reduced perineal pain compared to

no cream use during the early postpartum

period.

one participant received an episiotomy, with the most common perineal injury being a 1st (N = 10) or 2nd (N = 15) degree injury.

Perineal pain levels before treatment application at the beginning of the study period ranged from 0 to 82 mm (VAS possible range 0–100 mm), with an average (±SD) of 22.9 ± 21.9 mm (N = 27). Perineal pain adjuncts used by participants varied over the duration of the study, with ice packs only being used at the time of the 1st study treatment and rarely thereafter. Ibuprofen was used by the majority of participants throughout the study period (Table 1).

A reduction in pain was found after application of both the hydrocortisone and placebo creams, with av- erage perineal pain change scores of −4.8 ± 8.4 mm after treatment with hydrocortisone creams and −6.7 ± 13.0 mm after treatment with the placebo cream (N = 27). Changes in pain scores with no cream ap- plication were 1.2 ± 10.5 mm (N = 27). Analysis of variance found a significant difference between treat- ment groups (F

2,72 = 3.6, p = 0.03), with both cream

treatments having significantly better pain reduction than the control, no cream treatment (hydrocortisone vs. no cream, p = 0.04; placebo cream vs. no cream, p = 0.01) (Tables 2 and 3). The difference in perine- al pain reduction between the two cream treatments was not found to be statistically significant (p = .54). Treatment order, severity of perineal injury, and use of pain adjunct were not found to be significant factors accounting for changes in pain scores with the three treatments (p > 0.5).

Clinical Implications The primary fi nding of this study of 27 postpartum mothers was that the application of cream to the perine- al area signifi cantly reduced perineal pain compared to no cream application. Although both cream applications

did reduce pain after application, no difference was found in pain reduction between the two creams. Placebo cream was just as effective at pain reduction as the cream impregnated with hydrocortisone.

No previous studies have evaluated hydro- cortisone alone as method for treating peri- neal pain. Limited studies have previously evaluated the active ingredient of hydrocor- tisone in a topical medication, along with a topical anesthetic, pramoxine hydrochloride, in the foam preparation (Greer & Cameron, 1984; Hanretty et al., 1984; Hutchins et al., 1985). All of those studies compared active to placebo foam, with no true control group. Similar to our study results, a systematic re- view found that perineal pain at 24 to 72 hours after birth was no different between the active and placebo foam preparations (Hedayati et al., 2005). Unlike our study, though, these studies did not include a true control group with no active or placebo agent applied.

Our study results support that use of a cream, re- gardless of whether it is medicated or not, results in a significant reduction in perineal pain compared with not using a cream. Perhaps this is related to the soothing effect of the creams that add moisture to the affected area and provide a protective barrier, preventing irritation from possible friction. Although the study results showed a significant decrease in per- ceived perineal pain with use of cream, the study also showed that women, prior to treatment, rated their pain on average 21.5–24.8. These initial pain scores could be compared to “mild pain” on a pain scale of 0–10. According to Steen (2008, p. 391), “alleviating perineal pain is a very important aspect of postnatal care” and it is important that women are given op- tions to help alleviate their pain, even if initially rated as mild.

The cost of creams (1 oz tubes) at our institution are comparable (hydrocortisone 1% is $2.66; bland emollient cream is $2.05); there seems to, therefore, be little fi nancial incentive to use a bland cream rather than hydrocortisone cream. In addition to treating pain, hydrocortisone cream also has anti-infl ammatory properties that may help treat perineal edema related to vaginal birth. The minimal cost, as well as anti-infl ammatory properties, suggests that hy- drocortisone cream remains a viable option for treating perineal pain during the fi rst postpartum day.

Another fi nding of the study was that ibuprofen was the most common perineal pain adjunct used by post- partum mothers on the day of birth. Ice, which was used by 13 of the 27 participants for their fi rst perineal pain treatment within 4 hours of birth, was rarely used for subsequent treatments over the next 12 hours. Al- though our study did not attempt to query postpartum mothers about the reason for selecting various peri- neal pain adjuncts, clinicians often hypothesize that ice

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September/October 2015 MCN 311

pack applications are too cumbersome and/or diffi cult to maintain. It is possible that after trying the ice pack once, mothers determined it was either not helpful in pain relief or too cumbersome. A recent Cochrane review of cryotherapy studies in the postpartum pa- tient population found limited evidence to support the effectiveness of local cooling treatments in the relief of perineal pain (East et al., 2012). Further studies evaluating women’s perceptions of effective treatment modalities are needed.

Limitations

This study only evaluated one type of hydrocortisone cream and placebo cream. It is possible that results

may be different with other types of topical cream with other pain reduction and/or anti-infl ammatory active ingredients. Additional RCTs should evaluate this and other topical creams to determine their effectiveness compared to placebo creams and a control group for pain relief. Another limitation of the study was that

Table 3. Analysis of Variance Summary Table of Changes in Perineal Pain Visual Analog Scores (VAS; mm) Before and 30 to 60 Minutes After Treatment With Hydrocortisone Cream, Placebo Cream, or no Cream for N = 27 Postpartum Mothers

Source df SS MS F Power

Treatment type 2 874.754 437.377 3.619 .0318

Treatment order 2 75.150 37.575 .311 .7339

Treatment type X treatment order 4 257.099 64.275 .532 .7128

Residual 72 8702.725 120.871

Table 2. Changes in Perineal Pain Visual Analog Scores (VAS; mm) Before and 30 to 60 Minutes After Treatment With Hydrocortisone Cream, Placebo Cream, or no Cream for N = 27 Postpartum Mothers

Treatment Order of Treatment Change in Perineal Pain VAS

(30–60 min after–before)

Hydrocortisone cream All combined −4.8 ± 8.4

First (N = 10) −6.9 ± 10.1

Second (N = 7) −4.9 ± 9.8

Third (N =10) −2.8 ± 5.3

Placebo cream All combined −6.7 ± 13.0

First (N = 8) −5.9 ± 17.0

Second (N = 10) −10.4 ± 13.8

Third (N = 9) −3.4 ± 6.9

No cream All combined 1.2 ± 10.5

First (N = 9) 0.9 ± 10.8

Second (N = 10) 2.5 ± 11.5

Third (N = 8) 0.0 ± 10.2

This study was designed to determine if the use of hydrocortisone cream decreases perineal pain in the immediate postpartum period.

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312 volume 40 | number 5 September/October 2015

pain reduction was only evaluated in the fi rst day after vaginal birth. It is possible with longer use of topical creams different results would be found. And fi nally, the study is limited by the types of patients studied who primarily had 1st or 2nd degree perineal injuries, with only one patient having an episiotomy. Results may differ in patients with episiotomies and/or more severe perineal injuries.

Conclusions This RCT found that signifi cant perineal pain reduc- tion can be achieved within the fi rst postpartum day with the application of either a hydrocortisone cream or a cream with no active analgesic ingredients and were both signifi cantly better than no application of cream. ✜

Margaret Manfre is a Lactation Consultant, Mother Baby/GYN Unit, Lutheran Medical Center, Wheat Ridge, CO. She can be reached via e-mail at Margaret. [email protected]

Donita Adams is a Staff Nurse, Mother Baby/GYN Unit, Lutheran Medical Center, Wheat Ridge, CO.

Gloria Callahan is a Staff Nurse, Mother Baby/GYN Unit, Lutheran Medical Center, Wheat Ridge, CO.

Patricia Gould is a Staff Nurse, Mother Baby/GYN Unit, Lutheran Medical Center, Wheat Ridge, CO.

Susan Lang is a Staff Nurse, Mother Baby/GYN Unit, Lutheran Medical Center, Wheat Ridge, CO.

Holly McCubbins is a Staff Nurse, Mother Baby/GYN Unit, Lutheran Medical Center, Wheat Ridge, CO.

Amy Mintz is a Staff Nurse, Mother Baby/GYN Unit, Lutheran Medical Center, Wheat Ridge, CO.

Sommer Williams is a Staff Nurse, Mother Baby/ GYN Unit, Lutheran Medical Center, Wheat Ridge, CO.

Mark Bishard is a Pharmacist, Lutheran Medical Center, Wheat Ridge, CO.

Amy Dempsey is an OB Clinical Practice Specialist, Lutheran Medical Center, Wheat Ridge, CO.

Marianne Chulay is a Consultant, Clinical Research, Southern Pines, NC.

The authors declare no confl icts of interest.

DOI:10.1097/NMC.0000000000000165

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(2nd ed.). New York, NY: Academic Press. Corkill, A., Lavender, T., Walkinshaw, S. A., & Alfi revic, Z. (2001).

Reducing postnatal pain from perineal tears by using lignocaine gel: A double-blind randomized trial. Birth, 28(1), 22-27. doi:10.1046/ j.1523-536x.2001.00022.x

East, C. E., Begg, L., Henshall, N. E., Marchant, P. R., & Wallace, K. (2012). Local cooling for relieving pain from perineal trauma sustained during childbirth. Cochrane Database of Systematic Reviews, (5), CD006304.

Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G*Power 3: A fl exible statistical power analysis program for the social, behav- ioral, and biomedical sciences. Behavior Research Methods, 39(2), 175-191. doi:10.3758/BF03193146

Gélinas, C., Loiselle, C. G., LeMay, S., Ranger, M., Bouchard, E., & McCormack, D. (2008). Theoretical, psychometric, and pragmatic issues in pain measurement. Pain Management Nursing, 9(3), 120- 130. doi:10.1016/j.pmn.2007.12.001

Greer, I. A., & Cameron, A. D. (1984). Topical pramoxine and hydrocor- tisone foam versus placebo in relief of post partum episiotomy symptoms and wound healing. Scottish Medical Journal, 29(2), 104-106.

Hanretty, K. P., Davidson, S. E., & Cordiner, J. W. (1984). Clinical evalua- tion of a topical anaesthetic preparation (pramoxine hydrochloride and hydrocortisone) in post-episiotomy pain relief. British Journal of Clinical Practice, 38(11-12), 421-422.

Hedayati, H., Parsons, J., & Crowther, C. A. (2005). Topically applied anaesthetics for treating perineal pain after childbirth. Cochrane Database of Systematic Reviews, (2), CD004223.

Hjermstad, M. J., Fayers, P. M., Haugen, D. F., Caraceni, A., Hanks, G. W., Loge, J. H., …, Kaasa, S. (2011). Studies comparing numerical rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: A systematic literature re- view. Journal of Pain and Symptom Management, 41(6), 1073-1093. doi:10.1016/j.jpainsymman.2010.08.016

Hutchins, C. J., Ferreira, C. J., & Norman-Taylor, J. Q. (1985). A com- parison of local agents in the relief of discomfort after episiotomy. Journal of Obstetrics and Gynaecology, 6, 45-46. doi:10.3109/ 01443618509079138

Petersen, M. R. (2011). Review of interventions to relieve postpartum pain from perineal trauma. MCN. The American Journal of Mater- nal Child Nursing, 36(4), 241-245.

Steen, M. (2008). Understanding perineal pain: Women’s descriptions. British Journal of Midwifery, 16(6), 383-393.

Williamson, A., & Hoggart, B. (2005). Pain: A review of three commonly used pain rating scales. Journal of Clinical Nursing, 14(7), 798-804. doi:10.1111/j.1365-2702.2005.01121.x

Postpartum women received hydrocortisone cream, placebo cream, or no cream at three sequential perineal treatment times, with each treatment randomly assigned to be given for the fi rst, second, or third treatment.

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SPEAKING FROM THE HEART

An Introduction to Nonviolent Communication

A Language of Consideration Rather than Domination

Doro Kiley, Professional Certified Coach (540) 961-3997

[email protected] http://www.creationcoach.com

1

Introduction to Nonviolent Communication A Language of Consideration Rather than Domination Doro Kiley, Professional Certified Coach (540) 961-3997 [email protected]

http://www.creationcoach.com

Nonviolent Communication (NVC) is a process of connecting with people in a way that allows everyone’s needs to be met through empathizing with the universal needs we all share. It is a way of relating to ourselves and others out of an awareness of feelings and needs rather than judgments, labels, punishment, guilt or shame.

At the heart of NVC is the ability to connect to our own ‘humanness’ and to the

“humanness” of others. It is to see ourselves and each other not as objects or as ‘good’ or “bad,” but as whole, dynamic persons with varying combinations of feelings and needs. When we can express that which is alive in us in a nonjudgmental, non-blaming way we have a much greater chance of inspiring an empathic connection with others because as humans we all share these same qualities; e.g. the needs for trust, safety, appreciation, caring, freedom… the list goes on. When empathy is experienced in connection to another person (or to ourselves) we, as humans, have a natural desire to improve the life of that person. Within this connection an exchange can take place that greatly enhances the chances of getting everyone’s needs met.

THE JACKAL AND THE GIRAFFE

THE JACKAL: In NVC we use the Jackal to symbolize the life alienating, domination language most of us were raised with. The jackal, as an animal, is low to the ground, a scavenger, competitive and vicious. A jackal as a person is one who approaches people (including themselves), places and things through the lens of a Right/Wrong, Good/Bad judgments. They speak a language that instills fear, anger, guilt and shame. It often inspires painful obsessions and behaviors. The jackal sees everything as deserving either reward or punishment for themselves or others. Their language is demanding; “Do this.” “Don’t do that.” The jackal lives in their head judging, analyzing and blaming themselves and others.

THE GIRAFFE: In NVC we use the Giraffe to symbolize the life serving, partnership language that inspires connection and community. The giraffe is a very powerful yet peaceful, gentle animal. It has the largest heart of any land animal on earth and the longest neck which allows for a far, overall view of the world around it. To speak ‘giraffe’ is to speak from the heart. A giraffe person is non-judgmental, non-blaming, non-demanding and non-threatening. A giraffe is objective in their view and understanding of their feelings and needs as well as the feelings and needs of others. They practice empathy and desire to make life more wonderful for themselves and those around them.

Purpose of NVC

• To evoke an empathic, natural connection so that all needs may be met

2

• To consider and to connect to the life in ourselves and others • To be inspired and to inspire others to give out of the natural joy of giving

Background of NVC

• Founded by Marshall Rosenberg during the Civil Rights era; influenced by Carl Rogers

• The Center for Nonviolent Communication, founded in 1984, has international presence in such places as the Middle East, Bosnia, Rwanda, Columbia, Indonesia, Malaysia, Sri Lanka, Nigeria, Sierra Leone, India, Western Europe, and more.

• Most frequent applications include school systems, health care, prisons, workplaces, law enforcement & military, drug treatment & social services, families.

NVC - Based on 2 Principles

1. Principle #1 – Nurturing Our Nature We hold an acknowledgement that domination thinking and violence have been trained and habituated into us in a poor attempt to control others and be controlled by others. The basic premise of NVC is that this unskillful training, though thousands of years old, is not our true nature. Gandhi once said, “Don’t mistake habit for what is natural.” NVC is taught on the underlying supposition that our true nature is one of desire to make life more wonderful for ourselves and others. Unfortunately most of us have lost the skill and know-how to fulfill this desire. NVC is as much a process of unlearning old, unskillful reactions as it is gaining new tools and developing new responses.

2. Principle #2 - No One Makes You Feel We understanding that we are responsible for our own reactions to any given situation. Example: If identical triplets are on a beach and a wave comes and crashes down on them and recedes, one of the triplets may be exhilarated, thrilled and laughing, one may be furious, resentful and yelling while the third is despondent, frightened and crying. What made the difference? The difference comes not from what happened but rather from the fact that each of them has different needs, expectations, values and perceptions. The same can be said for any situation or interaction. It’s not that something or someone makes you feel anything but rather your needs are being met or not met.

NVC Model

The Four Components of NVC The first 3 components - observations, feelings and needs - make up the first part of the

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empathy process. This is a process of objectively identifying what’s really alive in you or another person. It’s an exploration of what ‘is’ without blame, judgment or analysis. It involves:

1. Observation (free of judgment, labels, diagnosis, opinions, etc.) ”When I see/hear/notice…”

2. Feeling (free of thoughts, not “I feel like..” or “I feel that…” We are also careful not to use ‘jackal’ words that imply blame such as bullied, ignored, cheated, betrayed, abandoned, victimized…) ”…I feel…” (happy, sad, delighted, frightened, surprised, angry, content, confused, thankful, anxious, affectionate, resentful, intrigued, overwhelmed, thrilled, etc…)

3. Need (universal; without reference to any specific person, time, activity)

”…because I am needing…” (trust, appreciation, freedom, understanding, connection, safety, hope, consideration, equality, integrity, respect, acceptance, autonomy, etc…)

The fourth component - the request - is the ‘dance’ that allows life to move forward. It presents the opportunity to make life more wonderful by moving toward a joyful resolution. The request is the ebb and flow of giving and receiving, back and forth, that provides the opportunity for everyone’s needs to be met.

NOTE: It’s important to remember that if you are the one expressing what’s alive in you then your request will always immediately follow your observations, feelings and needs. However, if you are the one providing empathy to someone else then you will not make a request until you’ve been given a ‘sign’ or have been asked to make a request.

4. Request (clear, positive, present, detailed, active request that would enrich life)

”Would you be willing to…?”

Jackal Example: Person #1: You never listen to me when I’m talking to you. You’re ignoring me constantly. You just don’t care! Person #2: Yeah right! I listen to you all the time! Person #1: You can’t listen to me and read the paper at the same time! You’re so unreal! Person #2: I’m unreal?! You don’t even…. (discussion goes nowhere and ends in frustration)

Giraffe Example: Person #1: When I see you read the newspaper while I’m talking, I feel frustrated because I’m needing to be heard. Would you be willing to close the newspaper for 5 minutes and hear my idea?

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Person #2: When you ask me to close the paper when I’m reading an article that is very important to me I feel anxious because of my need to understand what’s going on in the world. I also feel concerned because of my need for your well-being. Would you be willing to wait 5 minutes while I finish this article so I can give you my full attention? Person #1: Yes. Two Parts of NVC

1. RECEIVING EMPATHY Honestly EXPRESS your clear, nonjudgmental observations, your own feelings and needs; being aware of what’s alive in you o Ongoing awareness of observations, feelings and needs: “When I hear (see)… I

feel….because I need…. Would you be willing to…?” o Willingness and courage to express those feelings and needs (vulnerability) o Willingness to make clear, detailed requests

2. PROVIDING EMPATHY

Empathically LISTEN to other’s observations, feelings and needs o Presence, Focus, Space, Verbal reflection of feelings & needs:, “Are you

feeling…?”, “Are you needing…?” o NOT advising, fixing, consoling, story-telling, sympathizing, analyzing,

explaining, defending. o No matter what is said, hear only feelings, needs, observation & requests. o Make a request ONLY after being given a ‘sign’ or asked to do so.

SELF EMPATHY Transforming the Pain of Unmet Needs

Transforming our relationships often involves transforming ourselves at the same time. When 2 (or more) people are in pain because their needs aren’t being met it may seems like a stale mate; no one has enough empathy to get the ball rolling. In this situation self empathy is a tool to begin with. This practice can be done as many times as needed to soften the hard defenses and open the heart. It may take a minute, a day or two, sometimes more. You may chose to make it a daily practice which would be optimal.

1. Take Time & Space: When you are in pain take some time, create a space alone and undisturbed where you can write (or type) freely.

2. The Jackal Show: Just start writing. Don’t watch your words or try to “be nice”. Just let it flow. This is called the Jackal Show. You can write all about what ‘they’ have done to you, what they have created, what they’ve destroyed. You can express all your pain and anguish, your fears and outrage, your judgments, thoughts, analysis of the situation and whatever else comes to mind. Do this until you have nothing left to say.

3. List the Jackal Words: Go back over what you’ve written. What are the jackal words that come to mind? Make a list of the jackal words that imply blame such as; bullied,

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ignored, cheated, betrayed, abandoned, victimized…

4. Translate Jackals into Baby Giraffes: Go back over your jackal list. What are the real feelings behind all this? Make another list using your list of jackal translations. Remember that no one makes you feel anything. Your feelings are your own and are the results of your perceptions, beliefs and attitudes. Go behind the jackal words and get a real sense of the feeling words that describe what is going on in your body now such as; sad, frightened, angry, worried, confused, anxious, overwhelmed, bitter, jealous, etc… Use the Feelings List and pick out the words that describe the way you really feel. Each feeling is a baby giraffe crying with an unmet need. Feel them, listen to them. What are they trying to say? What needs are not being met?

5. List the Needs (not the strategies) Behind the Feelings: In this next list write down the unmet needs (not strategies) behind all these feelings such as; respect, appreciation, intimacy, recognition, cooperation, support… Use the Needs List to pick out the needs you have that are not being met. Remember these needs are not specific to any one person. An example of a need would be, “I need understanding.” An example of a strategy is, “I need you to understand me.” List only the needs not the strategies.

6. Mourning: Allow yourself to mourn the fact that these needs are not presently being met. Be with yourself. Give yourself permission to feel the pain of not having these needs met. It is painful. Hold your pain like you would hold a baby. If anger and resentment persist for a long time go back to writing more of the Jackal Show. Often once we have completed the first step a shift will take place and suddenly anger feels more like sadness. List the new feelings. List the needs behind those feelings. And allow yourself to mourn your loss again.

Empathy: When you feel complete with the above exercises allow yourself to sit back. The word “Empathy” implies an empty presence – an awareness of what is alive in you. Bring your awareness into your body. Every thought and emotion we have is manifesting in the body somewhere. Scan your body with all your senses gently and locate the places where you’re holding your pain. Don’t try to change anything. Just be empathic. Is your brow furrowed? Your shoulders tight? Your throat constricted? Your abdomen tight? Is your breathing shallow? When you find a place that is holding your pain just be present with it. If your shoulders suddenly relax, let them go. If your face muscles soften let it be. If your abdomen softens, breathe. NVC Resources … If you want to learn more about NVC

• Center for Nonviolent Communication: www.cnvc.org (Information, books, videos, audio tapes, training event listings, etc) • Book: Nonviolent Communication by Marshall Rosenberg

http://www.puddledancer.com/

Dr. Oz’s Transformation Nation – Million dollar YOU WeightWatchers

Family History Worksheet

How to Use This Worksheet 1. Talk to your family – your parents and siblings, primarily – about their health history. If

your siblings or parents are unavailable, ask your next closest relatives: first cousins, aunts and uncles, and grandparents.

2. Check the boxes next to the conditions that a family member has. If more than one family member has the condition, note how many in the box.

3. Return to Sharecare.com to enter your information. Keep this worksheet and take it with you to your doctor.

Condition Parent Siblings Other relative

Alzheimer’s disease

Allergies

Anemia

Anesthesia issues

Arthritis

Arthritis, Rheumatoid

Asthma

Bleeding issues

Cancer, Breast

Cancer, Colon

Cancer, Lung

Cancer, Skin

Cancer, Prostate

Cancer, Ovarian

Cancer (other)

Depression

Diabetes, Type 1 (childhood onset)

Diabetes, Type 2 (Adult onset)

Epilepsy (seizures)

Eye conditions

Glaucoma

Hearing problems

Heart disease, heart attack, stroke

Hight blood pressure/hypertension

Hight Cholesterol

Kidney disease

Lupus

Migraines

Osteoporosis

Thyroid disorder

Tuberculosis

Other:

Writing a Literary Blurb

What is a literary blurb? A literary blurb is a

brief insight into a piece of literature based on the reader’s

view. A reader writes about one particular aspect of a piece

of literature. That particular aspect may include why the

author used so much imagery or why did the author use the

contrast of light and dark imagery to write a particular story

or poem or what is the impact of the author’s use of diction

(word choice) to write a story or a poem or what is the

impact of the author using one character in contrast (foil) to

another character. The ideas of what could be included in a

blurb could go on and on.

Length of the literary blurb: The length of the

literary blurb for this class is always one page. One page is

the maximum and minimum length. In other words, the blurb

will not be shorter than one page and will not exceed the

length of one page.

What is the structure of the blurb: The blurb

consists of a main idea that is introduced immediately. To

support the point the reader is trying to make in the blurb,

the reader must use examples from the story or the poem

and cite those examples by including book numbers, page

numbers and line numbers where applicable. Cited

examples should reflect that the student has read the entire

reading assignment.